Obesity management: Dancing to the Bhangra beat

Sir,

Recently United States Preventative Task Force (USPTF) issued a statement on screening and management of obesity in adults and behavioral counseling interventions to promote a healthful diet and physical activity for cardiovascular disease prevention in adults. USPTF recommended that patients with BMI of 30 kg/m² or more be offered intensive, multicomponent behavioral counseling (Grade B recommendation).[1]

Questions arise about the relevance of these guidelines in a developing country like India. Communicable diseases constitute the biggest health care concern in such countries. However, in last many years non communicable diseases including obesity have been rising steeply. Misra et al. issued a consensus statement in 2009 regarding diagnosis or obesity and recommendation for its management.[2] These are similar to the USPTF recommendations, but with a few differences. The cutoff for obesity and overweight is lower for south Asians than Caucasians. Misra et al. recommend pharmacological and surgical management for selected cases, whereas USPTF guidelines are based only on intensive behavioral management.

Jacob et al. have written a detailed review about behavioral therapy management of obesity.[3] Recent USPSTF recommendations also focus on medium to high intensity behavioral interventions by primary physicians and community based organizations.[4] Lack of enough dieticians, nutritionists and psychologists may be a big hurdle for patient counseling. In India, where most of the patients pay from pocket, convincing them to pay for behavioral therapy would be a herculean task. It would make more sense to incorporate behavioral interventions in routine medical care. We have enough evidence and recommendations in favor of behavioral therapy. The challenge is to implement them in regular practices of primary physicians, in a low cost, low risk and universally accepted way.

Inappropriate dietary habits play a major role in the pathogenesis of obesity. Even in the US, a high calorie burger is available for one dollar where as a packet of salad is three times more expensive. Buying carbohydrate rich soda is much cheaper than buying natural water. Irony! In India, the problem is compounded by the fact that almost all traditional culinary is saturated with fat. The government should focus on reducing consumer costs for healthier foods, which will probably indirectly cut down health care costs, exponentially leading to a net savings.

Increasing physical activity is one of the other key components of this strategy. Similar guidelines exist across the two ends of the world.[2,5,6] None of them however, make it mandatory to use a health fitness center or a physical trainer specifically, as long the required duration and intensity of exercise is met. Rather, we should also focus on low cost ‘innovative’ ways of tackling the problem. An interesting editorial published by Unnikrishnan et al. about ways of dealing with obesity epidemic makes some important suggestions.[7] The authors mention low cost methods like walking, yoga, meditation and folk dances. Encouraging folk dances, which utilizes both upper limb and lower limb muscles, and lend them to aerobic exercise, like the vigorous bhangra, from the Punjab, may turn out to be the magic wand which can arrest the spread of obesity.

Obesity is a major health problem for developed and developing countries alike. Many cost effective ways are available to prevent and treat obesity, but they need to be popularized. Esteemed journals with wide circulation and impact like Indian Journal of Endocrinology and Metabolism should focus on spreading this message, and on improving their utility by continued research.